A Just-in-Time Video Primer on Pneumothorax Pathophysiology and Early Management

Audience Emergency medicine residents (interns, junior residents), medical students, and mid-level providers (physician assistants, nurse practitioners). Introduction Pneumothorax refers to the presence of gas within the pleural space and is a relatively common clinical entity in the emergency department.1 Traumatic pneumothorax results from blunt or penetrating trauma to the thorax. Iatrogenic pneumothorax is a risk inherent to a number of invasive procedures and represents a significant cause of preventable morbidity.2 Specifically, central venous catheterization (43.8%), thoracentesis (20.1%), and barotrauma due to mechanical ventilation (9.1%) are the most frequent causes.3 A feared complication of pneumothorax is the development of tension pneumothorax, which involves the compression of mediastinal structures by increased pressures within the pleural space, leading to hemodynamic compromise.4 As tension pneumothorax is an emergent, life-threatening condition, the management of pneumothorax and the insertion of chest tubes are skills required of physicians involved in the care of injured patients, including general surgeons, intensivists, and emergency medicine physicians.5 The process of correcting pneumothorax is not without complication. Complications following chest tube insertion in trauma patients occur in 19% of cases,6 and are commonly a result of chest tubes placed by resident physicians.7 The authors believe that a web-based learning module addressing topics related to pneumothorax (pathophysiology, clinical manifestations, diagnosis, and management) would be beneficial to healthcare providers who are likely to encounter pneumothorax in clinical practice. Specifically, the web-based nature of the module would lend itself to convenient viewing and would allow for utilization as a just-in-time training modality. Presenting these topics in an animated format may also be a useful way of capturing the complex and three-dimensional nature of respiratory physiology. Additionally, the web-based format may be particularly appealing to digital native natives, who occupy an increasing percentage of resident physician positions.8 It should be noted that a number of studies have examined the use of computerized modules in medical education, and found them to be at least as useful as traditional instructional methods, and are typically associated with high rates of satisfaction among learners.9–13 Educational Objectives By the end of this module, participants should be able to: Review the normal physiology of the pleural space Discuss the pathophysiology of pneumothorax Describe the clinical presentation of pneumothorax Identify pneumothorax on a chest radiograph Review treatment options for pneumothorax Educational Methods This is a video podcast, which conveys information through animated content. It is available to learners on demand and just-in-time for practice. It may be used as a stand-alone educational tool, as a primer to other instructional methods (eg, simulation), or a just-in-time training tool. Research Methods A small-scale study was conducted to evaluate the efficacy of this module as an educational tool. The learner group consisted of a convenience sample of 11 second-year medical students at the end of their pre-clinical training. All learners were administered the attached assessment form as a pre-test, shown the video, then asked to re-take the assessment as a post-test to assess improvement. Assessments were graded on a 10-point scale according to the attached answer key. Learners were also given the opportunity to rate the quality of the module as an educational tool, as well as to provide subjective feedback. Results The average pre-test score across all learners was 34%. The average post-test score across all learners was 82%, representing an improvement of 48%. Learners were asked to rate their agreement with the statements, “This module effectively taught concepts related to pulmonary physiology and pneumothorax,” and, “The animated format of this module was useful for illustrating concepts related to pulmonary physiology and pneumothorax.” All learners responded with “agree” or “strongly agree” for each statement. When given the opportunity to provide subjective feedback regarding the module, learners responded with “This module is a great review! It is well organized, has effective animations, and information is clear,” and “Helpful review that explained the concepts in an accessible way!” Discussion Results from the pre-test and post-test suggest that this module was effective in teaching concepts related to pulmonary physiology and pneumothorax. All learners reported satisfaction with the animated format in particular. These results suggest that this module would be effective as a standalone educational tool or as a primer to other instructional methods. Topics Pneumothorax, thoracostomy, needle decompression, flipped classroom, asynchronous learning, emergency medicine.

of the module would lend itself to convenient viewing and would allow for utilization as a just-in-time training modality. Presenting these topics in an animated format may also be a useful way of capturing the complex and three-dimensional nature of respiratory physiology. Additionally, the web-based format may be particularly appealing to digital native natives, who occupy an increasing percentage of resident physician positions. 8 It should be noted that a number of studies have examined the use of computerized modules in medical education, and found them to be at least as useful as traditional instructional methods, and are typically associated with high rates of satisfaction among learners. 9-13 Educational Objectives: By the end of this module, participants should be able to: 1) Review the normal physiology of the pleural space 2) Discuss the pathophysiology of pneumothorax 3) Describe the clinical presentation of pneumothorax 4) Identify pneumothorax on a chest radiograph 5) Review treatment options for pneumothorax Educational Methods: This is a video podcast, which conveys information through animated content. It is available to learners on demand and just-in-time for practice. It may be used as a stand-alone educational tool, as a primer to other instructional methods (eg, simulation), or a just-in-time training tool.

Research Methods:
A small-scale study was conducted to evaluate the efficacy of this module as an educational tool. The learner group consisted of a convenience sample of 11 second-year medical students at the end of their pre-clinical training. All learners were administered the attached assessment form as a pre-test, shown the video, then asked to re-take the assessment as a post-test to assess improvement. Assessments were graded on a 10-point scale according to the attached answer key. Learners were also given the opportunity to rate the quality of the module as an educational tool, as well as to provide subjective feedback.

Results:
The average pre-test score across all learners was 34%. The average post-test score across all learners was 82%, representing an improvement of 48%. Learners were asked to rate their agreement with the statements, "This module effectively taught concepts related to pulmonary physiology and pneumothorax," and, "The animated format of this module was useful for illustrating concepts related to pulmonary physiology and pneumothorax." All learners responded with "agree" or "strongly agree" for each statement. When given the opportunity to provide subjective feedback regarding the module, learners responded with "This module is a great review! It is well organized, has effective animations, and information is clear," and "Helpful review that explained the concepts in an accessible way!" Discussion: Results from the pre-test and post-test suggest that this module was effective in teaching concepts related to pulmonary physiology and pneumothorax. All learners reported satisfaction with the LECTURES 22 Section break animated format in particular. These results suggest that this module would be effective as a standalone educational tool or as a primer to other instructional methods.

Linked objectives and methods:
This module instructs learners on pneumothorax using an animated format, which is useful for conceptualizing the complexities of pleural physiology (objective 1), as well as the pathophysiologic mechanisms of pneumothorax (objective 2).
Participants will also learn about the range of presentations of pneumothorax (objective 3), which vary based on severity of disease. In addition to animations, this module contains representative radiographic images displaying the characteristic changes seen with pneumothorax (objective 4). A discussion of the available treatment options for pneumothorax is also included, as well as animated demonstrations of these maneuvers (objective 5).
Recommended pre-reading for instructor:

Roberts and Hedges' Clinical Procedures in Emergency
Medicine,¹⁴ Section II, Chapter 10: Tube Thoracostomy.

Results and tips for successful implementation:
A small-scale study was performed to evaluate the efficacy of this module as an educational tool. The learner group consisted of a convenience sample of 11 second-year medical students at the end of their pre-clinical training. Learners were administered the attached assessment form as a pre-test, shown the module, and then asked to re-take the assessment as a post-test to assess improvement. The average pre-test score across all learners was 34%. The average post-test score across all learners was 82%, representing an improvement of 48%. Learners unanimously agreed that the module was effective for teaching concepts related to pulmonary physiology and pneumothorax. These results suggest that this module would be effective as a standalone educational tool or as a primer to other instructional methods.